Image-guided Surgical Techniques Research Articles

"Beyond the Knife"-Applying Theranostic Technologies to Enhance Outcomes in Neurosurgical Oncology.

The current standard of care for brain tumor management includes maximal safe surgical resection followed by concurrent chemotherapy and radiation therapy. Recent advances in image-guided surgical techniques have enhanced the precision of tumor resections, yet there remains a critical need for innovative technologies to further improve patient outcomes. Techniques such as fluorescence image-guided neurosurgery in combination with stereotactic radiosurgery have improved outcomes for patients with brain tumors. In this article for Brain Science's Special Issue Recent Advances in Translational Neuro-Oncology, we review the use of image-guided neurosurgery and stereotactic radiosurgery for the treatment of brain tumors. In addition, we summarize the emerging use of theranostic nanoparticles for the delivery of diagnostic and therapeutic technologies to enable the neurosurgeon to perform more precise surgical resections in the operating room, to specifically target the delivery of existing and novel treatments to tumor cells, and to augment the efficacy of stereotactic radiosurgery. These innovative translational tools will allow neurosurgeons, neuro-oncologists, and radiation oncologists to go "beyond the knife" to improve the survival of brain tumor patients.

Impact of image-guided surgical techniques in complex bone reconstruction for maxillofacial fractures

Maxillofacial fractures present complex surgical challenges that require precise reconstruction techniques. Image-guided surgical methods, including computer navigation and 3D imaging, are increasingly used to improve surgical outcomes, yet selecting the optimal modality remains difficult due to the varying benefits of each technology. The databases used in the current research include, but are not limited to, PubMed, Scopus, and Google Scholar for article searches. Controlling for sources of bias, the review selected publications on image-guided surgical approaches to managing craniofacial fractures. Studies were identified based on the following criteria: methodology, relevance and patient-oriented results. Thus, analytical categories were developed to evaluate the results, including surgical meticulousness, complication incidences healing, and overall patient satisfaction. The research shows that the availability of enhanced imaging tools and navigation, including CT-nav, 3D-image ster, and intra-operative CBCT, enhances surgical precision and diagnostic accuracy. Preoperative planning repeatability when using CAN was up to 86.5%, and the need for revisions in maxillofacial trauma patients was reduced. Research on computation mirroring for navigation found differences between 0.12 mm, revealing enhanced surgery accuracy. Evaluations of image-guided techniques indicate their advantage over other methods in maxillofacial fracture operations in terms of accuracy and efficiency. Even nowadays, they provide significant improvements in patients’ treatment and surgical precision despite certain shortcomings in terms of technology and availability. Further studies need to consider enhancements to the navigation systems and consider cost benefits, depending on the type of setting in which the patient is located.

Effect of the cone-beam CT acquisition trajectory on image quality in spine surgery: experimental cadaver study

BACKGROUNDIntraoperative 3D imaging with cone-beam CT (CBCT) improves assessment of implant position and reduces complications in spine surgery. It is also used for image-guided surgical techniques, resulting in improved quality of care. However, in some cases, metal artifacts can reduce image quality and make it difficult to assess pedicle screw position and reduction. PURPOSEThe objective of this study was to investigate whether a change in CBCT acquisition trajectory in relation to pedicle screw position during dorsal instrumentation can reduce metal artifacts and consequently improve image quality and clinical assessability. STUDY DESIGNExperimental cadaver study. METHODSA human cadaver was instrumented with pedicle screws in the thoracic and lumbar spine region (Th11 to L5). Then, the acquisition trajectory of the CBCT (Cios Spin, Siemens, Germany) to the pedicle screws was systematically changed in 5° steps in angulation (−30° to +30°) and swivel (−25° to +25°). Subsequently, radiological evaluation was performed by 3 blinded, qualified raters on image quality using 9 questions (including anatomical structures, implant position, appearance of artifacts) with a score (1–5 points). For statistical evaluation, the image quality of the different acquisition trajectories was compared to the standard acquisition trajectory and checked for significant differences. RESULTSThe angulated acquisition trajectory significantly increased the score for subjective image quality (p<.001) as well as the clinical assessability of pedicle screw position (p<.001) with particularly strong effects on subjective image quality in the vertebral pedicle region (d=1.61). Swivel of the acquisition trajectory significantly improved all queried domains of subjective image quality (p<.001) as well as clinical assessability of pedicle screw position (p<.001). CONCLUSIONSIn this cadaver study, the angulation as well as the swivel of the acquisition trajectory led to a significantly improved image quality in intraoperative 3D imaging (CBCT) with a constant isocenter. The data show that maximizing the angulation/swivel angle towards 30°/25° provides the best tested subjective image quality and enhances clinical assessability. Therefore, a correct adjustment of the acquisition trajectory can help to make intraoperative revision decisions more reliably. CLINICAL SIGNIFICANCEThe knowledge of enhanced image quality by changing the acquisition trajectory in intraoperative 3D imaging can be used for the assessment of critical screw positions in spine surgery. The implementation of this knowledge requires only a minor change of the current intraoperative imaging workflow without additional technical equipment and could further reduce the need for revision surgery.

ПОЧЕЧНО-КЛЕТОЧНЫЙ РАК ТРАНСПЛАНТАТА ПОЧКИ: ОПИСАНИЕ КЛИНИЧЕСКОГО СЛУЧАЯ И КРАТКИЙ ОБЗОР ЛИТЕРАТУРЫ

A retrospective analysis of a patient with renal cell carcinoma (RCC) in renal allografts is presented, providing a comprehensive overview of the patient's medical history, the findings from various examinations, and the surgical interventions. The patient had end-stage renal disease due to nephrosclerosis following a kidney allotransplantation in 2008 and subsequently developed chronic allograft nephropathy. Upon examination, a tumor was discovered in the lower pole of the transplanted kidney. As a result of the end-stage renal transplant failure development, the patient underwent radical surgical treatment using advanced image-guided surgical techniques. This case is a compelling example of the critical importance of regular, thorough screenings for patients undergoing immunosuppressive therapy to identify any potential neoplastic processes promptly. Keywords: Kidney transplantation, kidney carcinoma, renal allograft embolization, transplant nephrectomy.

How to objectively evaluate the impact of image-guided surgery technologies.

This manuscript aims to provide a better understanding of methods and techniques with which one can better quantify the impact of image-guided surgical technologies. A literature review was conducted with regard to economic and technical methods of medical device evaluation in various countries. Attention was focused on applications related to image-guided interventions that have enabled procedures to be performed in a minimally invasive manner, produced superior clinical outcomes, or have become standard of care. The review provides examples of successful implementations and adoption of image-guided surgical techniques, mostly in the field of neurosurgery. Failures as well as newly developed technologies still undergoing cost-efficacy analysis are discussed. The field of image-guided surgery has evolved from solely using preoperative images to utilizing highly specific tools and software to provide more information to the interventionalist in real time. While deformations in soft tissue often preclude the use of such instruments outside of neurosurgery, recent developments in optical and radioactive guidance have enabled surgeons to better account for organ motion and provide feedback to the surgeon as tissue is cut. These technologies are currently undergoing value assessments in many countries and hold promise to improve outcomes for patients, surgeons, care teams, payors, and society in general.

Robotic Mastoidectomy

Using image-guided surgical techniques, we propose that an industrial robot can be programmed to safely, effectively, and efficiently perform a mastoidectomy. Whereas robotics is a mature field in many surgical applications, robots have yet to be clinically used in otologic surgery despite significant advantages including reliability and precision. We designed a robotic system that incorporates custom software with an industrial robot to manipulate a surgical drill through a complex milling profile. The software controls the movements of the robot based on real-time feedback from a commercially available optical tracking system. The desired path of the drill to remove the desired volume of mastoid bone was planned using computed tomographic scans of cadaveric specimens and then implemented using the robotic system. Bone-implanted fiducial markers were used to provide accurate registration between computed tomographic and physical space. A mastoid cavity was milled on 3 cadaveric specimens with a 5-mm fluted ball bit. Postmilling computed tomographic scans showed that, for the 3 specimens, 97.70%, 99.99%, and 96.05% of the target region was ablated without violation of any critical feature. To the best of our knowledge, this is the first time that a robot has been used to perform a mastoidectomy. Although significant hurdles remain to translate this technology to clinical use, we have shown that it is feasible. The prospect of reducing surgical time and enhancing patient safety by replacing human hand-eye coordination with machine precision motivates future work toward translating this technique to clinical use.

Management of painful osteoporotic vertebral compression fractures: Vertebroplasty and kyphoplasty

Osteoporosis is a serious public health problem among the aged, predominantly affecting women. Osteoporosis-related fragility fractures, nearly half of which involve the spine, are highly debilitating and contribute significantly to rising health care costs. Vertebroplasty and kyphoplasty are image-guided surgical techniques that have recently been developed to restore functionality through pain relief and fracture stabilization utilizing bone cement. Both procedures are minimally invasive, and therefore provide a low-cost alternative to open surgical interventions for vertebral compression fractures. Kyphoplasty is a technological modification of vertebroplasty and addresses the restoration of vertebral height in addition to structural rigidity. This article presents a description of both techniques and a literature review of the potential each holds for successful treatment of osteoporotic vertebral compression fractures. Recently reported outcomes comparing the two techniques are presented. A number of case reports, short-term studies, retrospective, and prospective cohort studies suggest that both vertebroplasty and kyphoplasty are effective for pain relief. Furthermore, neither is associated with significant short-term complications. Technological advances in cement materials, biomechanical modeling of the structural effects on adjacent vertebrae, and the need for large multi-center, long-term, randomized prospective clinical trials are currently emerging from the promise that these techniques hold for effective treatment of painful osteoporotic vertebral compression fractures.

Update on NIBIB Appropriations

Academy of Radiology Research President Philip O. Alderson, MD, testified on May 2, 2002, before the House Appropriations Subcommittee on Labor, Health and Human Services, and Education in support of increased fiscal year 2003 appropriations for the National Institute of Biomedical Imaging and Bioengineering (NIBIB). The Congress is currently considering legislation to appropriate funds for the National Institutes of Health (NIH), and Dr Alderson’s appearance before the House Subcommittee was part of the Academy’s effort to ensure that NIBIB has sufficient resources to achieve its mission. In his remarks before the Subcommittee, Dr Alderson expressed his agreement with new NIH Director Elias Zerhouni’s earlier statement before the Senate Health, Education, Labor, and Pensions Committee that the NIH needs “to encourage cross-cutting initiatives” (1). The NIBIB, Dr Alderson observed, “represents precisely such a cross-cutting initiative.” For example, Dr Alderson said “basic, cross-cutting research in molecular imaging supported by NIBIB could make broadly applicable new diagnostic tools available more quickly than would be possible if disease-specific research in the other institutes were the only way to accomplish these goals at the NIH, and new techniques in NIBIB could be applied to studies in all the other institutes.” Dr Alderson emphasized the important scientific opportunities that could be exploited by the NIBIB, including initiatives to develop novel imaging systems and new image-guided surgical techniques. Such opportunities could be lost, he said, if additional funds are not provided in the fiscal year 2003 appropriation. Dr Alderson told the Subcommittee that

Open MRI-guided neurosurgery.

A number of different image-guided surgical techniques have been developed during the past decade. None of these methods can provide the surgeon with information about the dynamic changes that occur intra-operatively. The first vertical open 0.5T MRI-scanner for intra-operative MRI-guided neurosurgery in Germany was installed at the University of Leipzig during the summer 1996. Since autumn 1996 a number of surgical procedures including biopsies (n = 31), craniotomies (n = 32), transsphenoidal procedures (n = 8) and interstitial lasertherapies (n = 3) have been performed using intra-operative MR image guidance. The development of MR-compatible and MR-safe non-magnetic instruments and components had to be solved. Specific surgical instruments were developed to perform biopsies, craniotomies, microsurgical tumour resections and transsphenoidal procedures in the 0.5-T open MRI. Several components required adaptation including the head holder the stereotactic navigation device, the high speed drill, the suction unit, the ultrasonic aspirator, the bipolar coagulation, the laser probe and the surgical microscope. All these newly developed technical features enable the neurosurgeon to perform a large number of surgical procedures under direct control and guidance of intra-operative MR imaging. In contrast to frame-based for framless navigation systems, intra-operative MRI provides accurate and immediate information during the progress of surgery. These intra-operative images allow definitive localization and targeting of the lesions and accommodate anatomical changes that may occur during surgery. Intra-operative MRI is helpful for navigation as well as determining of tumour margins to achieve a complete and safe resection of intracranial lesions. Complications related to the surgical procedure are reduced and the risk of neurological deterioration due to tumour removal and postoperative complications is minimized. It can be concluded that the intra-operative application of interventional MRI technology may represent a major step forward in the field of neurosurgery.

Image-Guided Surgical Techniques for Infections and Trauma of the Central Nervous System

The value of image-guided stereotactic systems is directly dependent on the ease and speed of their use. In the past, most stereotactic techniques were complicated and timely to set up; thus, they were used exclusively for either resecting neoplasms or for neurologic function. However, current systems equipped with advanced registration techniques are much simpler and faster to employ, and indications for their use are rapidly increasing. We describe an advanced image-guided navigation system and provide examples of its successful use in neurosurgical treatment of central nervous system infection and trauma.